State of Wisconsin FORM G – Request for Proposal
DOA-3261 (R05/2014)
s. 16.75, Wis. Statutes
PROPOSALS MUST BE SEALED AND ADDRESSED TO:Remove from vendor list for this commodity/service. (Return this page only.)
AGENCY ADDRESS:Department of Employee Trust Funds
P.O. Box 7931
Madison, WI 53707-7913 / Proposal envelope must be sealed and plainly marked in lower corner with due date and Request for Proposal ETG0013. Late Proposals will be rejected. Proposals MUST be date and time stamped by the soliciting purchasing office on or before the date and time that the Proposal is due. Proposals dated and time stamped in another office will be rejected. Receipt of a Proposal by the mail system does not constitute receipt of a Proposal by the purchasing office. Any Proposalwhich is inadvertently opened as a result of not being properly and clearly marked is subject to rejection. Proposals must be submitted separately, i.e., not included with sample packages or other Proposals. Proposal openings are public unless otherwise specified. Records will be available for public inspection after issuance of the notice of intent to award or the award of the contract. Proposer should contact the person named below for an appointment to view the Proposal record. Proposals shall be firm for acceptance for one hundred eighty (180) days from date of Proposal opening, unless otherwise noted. The attached terms and conditions apply to any subsequent award.
REQUEST FOR PROPOSAL
ETG0013 –Administrative Services for the State of Wisconsin Pharmacy Benefit Program / Proposals MUST be in this office no later than
January 25, 2017 2:00PM CST / Public Opening
No Public Opening
PROPOSER (Name and Address) / Name (Contact for further information)
Beth Bucaida
Phone
608-267-3933 / Date
November 18, 2016
Quote Price and Delivery FOB
Services - Destination – Madison WI
Description
Request for Proposals (RFP) ETG0013- Administrative Services for the State of Wisconsin Pharmacy Benefit Program
For the Department of Employee Trust Funds (ETF).
RFP ETG0013amendments, questions and answers will be posted on the ETF website and will not be mailed.
*** Faxed and e-mailed Proposals are not accepted. ***
This page must be signed and included with the Proposal.
In signing this proposal we also certify that we have not, either directly or indirectly, entered into any agreement or participated in any collusion or otherwise taken any action in restraint of free competition; that no attempt has been made to induce any other person or firm to submit or not to submit a Proposal; that this Proposal has been independently arrived at without collusion with any other proposer, competitor or potential competitor; that this Proposal has not been knowingly disclosed prior to the opening of Proposals to any other proposer or competitor; that the above statement is accurate under penalty of perjury.
We will comply with all terms, conditions and specifications required by the State in this Request for Proposal and all terms of our Proposal.
Name of Authorized Company Representative (Type or Print) / Title / Phone( )
Fax ( )
Signature of Above / Date / Federal Employer Identification No. / Social Security No. (if Sole)
Proprietor (Voluntary)
This form can be made available in accessible formats upon request to qualified individuals with disabilities.